Nursing Elites

1. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?

• A. Decrease the oxytocin infusion rate
• B. Determine current cervical dilation
• C. Request placement of the epidural
• D. Give a bolus of intravenous fluids

Correct answer: D

Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.

2. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?

• A. Auscultate the lungs for respiratory pneumonia.
• B. Change to latex-free gloves when handling infant.
• C. Draw blood to analyze for streptococcal infection.
• D. Apply zinc oxide to perineum with each diaper change.

Correct answer: B

Rationale: Latex allergy is a concern in patients with myelomeningocele, so switching to latex-free gloves is important.

3. The healthcare provider is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the healthcare provider withhold the drug?

• A. Respiratory rate of 22 breaths/min
• B. A large amount of lochia rubra
• C. Blood pressure 149/90
• D. Positive Homan’s sign

Correct answer: C

Rationale: A blood pressure of 149/90 is an indication to withhold Methergine due to its potential to further increase blood pressure. Methergine is a medication that can cause vasoconstriction, leading to elevated blood pressure. In this case, administering Methergine could exacerbate the elevated blood pressure, posing a risk to the patient. Therefore, it is crucial to withhold the medication in the presence of hypertension to prevent adverse effects. The other options are not directly related to the administration of Methergine. A respiratory rate of 22 breaths/min is within the normal range. A large amount of lochia rubra may indicate normal postpartum bleeding. A positive Homan’s sign is associated with deep vein thrombosis, which is not a contraindication for administering Methergine.

4. During a prenatal visit, the LPN/LVN discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have

• A. lower Apgar scores.
• B. lower birth weights.
• C. respiratory distress.
• D. a higher rate of congenital anomalies.

Correct answer: B

Rationale: When mothers smoke during pregnancy, it is associated with intrauterine growth restriction, which leads to lower birth weights in infants. Maternal smoking can restrict the flow of oxygen and nutrients to the fetus, affecting its growth and development. This can result in babies being born with lower birth weights, which can have various health implications for the newborn. Choices A, C, and D are incorrect as smoking during pregnancy is primarily linked to intrauterine growth restriction and lower birth weights in infants, rather than lower Apgar scores, respiratory distress, or a higher rate of congenital anomalies.

5. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client’s blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?

• A. Notify the healthcare provider of the assessment findings.
• B. Administer analgesics as prescribed.
• C. Increase the client’s fluid intake.
• D. Monitor the client’s vital signs every hour.

Correct answer: A

Rationale: A severe headache post-delivery could indicate a serious condition such as preeclampsia or a spinal headache, which requires immediate medical attention. Notifying the healthcare provider of the assessment findings allows for prompt evaluation and appropriate management of the client's condition.

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